My Uncle John put up a very interesting response to the last important post that I put up (no not the one about the snow). I realized that I had probably not completely made myself clear when I read his first line, “Your anger concerns me.” Oops. I did not mean to sound angry by any means, a little upset about a flaw I perceive about the medical system, but not angry. Instead of simply copying, pasting and responding to what Uncle John said, I decided to simply write a follow up in response to the issues he brought up. So here goes.
First, I would like to say that I do not want to reduce the amount of choices in medicine. On the contrary, I want to increase choices for everyone involved. In my health services class we have been discussing some extremely interesting topics such as serving the un- and under-insured, bringing up the level of service to people who can’t afford it, and what would happen if we had a true free market economy within the realm of medicine. The US does have the closest relationship to a free market of all the industrialized nations and I’m very glad of it. In fact I wish we had a bit more of one. I would love to be able to truly be a good “shopper” and be able to find the best care available for what I can afford, and not be forced to accept a lesser value of care at a certain facility because my insurance company won’t pay for my care somewhere else.
Also, I agree with Uncle John that the bottom line in business should not be categorized as being either good or bad. The problem that I see and wish to address is a not so noticeable anti-competitive trust that seems to be going on in the medical field today. It’s not necessarily a control on prices as much as it is a control on information given to the patient. The idea that “doctor knows best” is extremely patronizing and creates a problem in the realm of informed consent. The definition of informed consent means that the doctor, hospital, what-have-you, tells you the risks of the procedure and the probabilities of the outcomes in order for you, the patient, to make a rational decision based on the information you’ve been given about the care you wish to receive. The thing that I think is going on is that patients are not getting enough information in order to make an informed decision about their care.
At the OB clinic where I shadowed a couple of summers back, I believe that the physicians were truly trying to think about their patients, but I also noticed that while they were mentioning epidurals and induction to every pregnant woman they saw, they were not always mentioning some of the outcomes that could result from having these procedures. If the patient had prior information about these procedures and questioned their usage, then the physicians would go into more detail about the procedures and outcomes. An epidural completely numbs the lower half of your body creating a scenario where you have a hard time knowing when to push for contractions during a normal vaginal delivery, causing labor to be longer, which could increase fetal distress and subsequently require an emergency c-section in order to “save the baby.” By marketing the option to reduce pain for the mother during labor, the physicians I shadowed were not illuminating all of the possible outcomes of the procedure.
The article that I cited in the last post was much more socialistic than my own position and I’m sorry that it might have come across as what I thought should be the future of medicine. What I wanted to address, and seemed to have not done the best job, was the fact that patients are not being given the necessary resources to make the best decisions.
I would just like to reiterate that my motivation for becoming a midwife is not vindictive. I am not out to stick it to the medical field. I want to become a midwife primarily because I have always been interested in natural healing, as I said earlier in the post. The article was simply something that opened my eyes a little wider to the thought that I’ve had for a long time that patients are not always treated like thinking adults as I believe they should be. One of the largest appeals for me about natural forms of medicine, like midwifery, is that it takes into account that people can make decisions about their care and should be part of the decision process instead of simply doing the first thing offered by a doctor. We need to be more mindful of the information that we’re receiving and not always take everything at face value. I’m not denigrating the knowledge of physicians; in fact I’m very glad that they have the fortitude to go through the rigors of medical school and residency in order to serve me as a member of the public. I just want to be a more informed consumer and be able to have the best care for my particular needs.
If a doctor thinks that induction and c-section are the best care for me and my children, I want to know all the whys and probabilities involved, not just be told that it’s a safe procedure and lots of people have had it done safely. If there are better alternatives for my particular care and the care of my children, I want to be able to make a choice with all the options in front of me. I think the growing popularity of midwifery for birth is not necessarily due to its inexpensiveness or efficiency (even though those are powerful arguments for someone poor like me) but the fact that midwives can be more focused on fine tuning their care to best suit the needs of their patients.
The problems are not black and white and neither are the answers. There are a lot of gray areas that need to be addressed. But this is one area where I might be able to help address what’s going on and be a part of the solution.
neumatikos 
I’ve thought about being a doula, but the only training classes I know of are out of state, so that’s out. Maybe sometime in the future, or something.
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There are two particular programs that I’m interested in and they’re both out of state for me. One’s in Maine and the other is in Vermont. There are two types of midwives: regular certified midwives or certified nurse-midwives. I don’t want to be a nurse so I want to go to one of the few accredited programs just for becoming a midwife.
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http://www.bradleybirth.com
If you can’t do the doula training, consider this. Christie has given birth twice with unmedicated vaginal deliveries, the first labor lasting a total of 56 hours, the last 23 under induction due to failure to progress after a premature membrane rupture. The Bradley method is all about preparation for birth. Since pain is relative, the definition of pain for a couch patatoe is different than that of a trained athlete. A Bradley trained couple who has properly done their exercises and preparation will not be overwhelmed in labor and demand meds like a woman who just waits 9 months for labor to begin. The Bradley people are always looking for new trainers who are willing to host classes and pass the natural method of childbirth preparation on to others. Several of the midwives we’ve talked to got started with doing a Bradley birth themselves, then teaching Bradley, and then progressing into midwifery.
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Also, as a side note, Christie found a OB/GYN here in Tulsa that also trained in Britain to learn traditional certified midwifery. It was great to have a doctor that mentioned the medical options available, but openly admitted that he didn’t recomend them. We recently talked to a woman who wanted to use him for her pregnancy but when she wanted to schedule certain delivery procedures designed soly for the woman’s convienience and no real medical benifit, he politly asked her to find another doctor. I wish there were more doctors like him!
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Yeah, I went through Bradley classes with my first and had a nearly drug-free birth. Couldn’t afford classes the 2nd time, but had a completely drug free birth.
I’d be more interested in being a doula and being there as a support person than to teach classes.
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It has always frustrated me when I perceive my doctors are talking down to me or that they are making acceptable risk determinations without my consensus. After all I am educated well enough in the sciences to understand the kinds knowledge they are using and how that knowledge was derived. This used to happen a lot until I came to the realization that they wouldn’t know what I know unless I talk to them. It doesn’t happen much anymore but when it does I ask a question or two and we get back to the two-way communication I desire. The problem I had was not that the doctors were using their perceived authority incorrectly; it was they did not know how to communicate with me until I communicated with them. I have learned that they typically use risk communication techniques when they are unsure as to the receiptability of the information that have to convey.
I have taken two risk communication workshops and will take it again if I get the chance. I think it is very important for everyone to know how to convey sensitive or controversial information in low trust, high-concern situations. It is very important at times, like when you need to tell your boss something they don’t what to hear, during disagreements with you spouse, or in the case of medical professionals when they need to convey a diagnosis. In fact, the university research into risk communications was started when it was observed how poorly Doctors communicated with terminal ill patents. I found a book on Amazon “Risk, Communication & Health Psychology” by Dianne Berry that I will send to you as soon as it arrives. I wish I had a book which I have read on risk communication to send you but all I have is some slides from the workshops which only mean something if you were at the workshop. I hope it is a good book on this important subject.
There are four main theoretical constructs in risk communication: Mental Noise Theory, Risk Perception Theory, Trust Determination Theory, and Negative Dominance Theory. The first Mental Noise Theory is simply that people who are upset have a difficulty hearing and processing information. This is probably a good description of an OB clinic. It has been clinically measured that upset people only hear or retain 15-20% of the information communicated to them. What is worse it has been shown that upset people stop hearing after 15 minutes. I can attest to that thinking back on some of my disagreements with Judy. In mental noise situations, effective communication needs to be short simple and clear as well as limited and repeated. It is unfortunate that this does not lend itself to informed consent for multifaceted medical options. It is also unfortunate that if the communication is done poorly the medical professional will be perceived as patronizing. That leads to the second construct, Risk Perception Theory.
Risk Perception Theory states what is perceived as real is real in its consequences. If I perceive a Doctor as talking down to me then I will discount their recommendations. This is true if they actually thought they were superior or any other reason. It gets worse if I don’t challenge my own perceptions. Over time the perceptions become opinions and then beliefs. Once formed, a belief is difficult or impossible to change. Also not perceptions are equal; negative perceptions become beliefs quicker than positive ones. This is why negative campaigning works in politics. That leads to the last construct, Negative Dominance Theory.
Negative Dominance Theory states when people are upset they tend to think negatively. Again, I can attest to that remembering disagreements Judy and I have had over the years. In clinical test it has been shown that on average one negative is equivalent to three positives. For example if you are explaining medical options and you communicate one option having two negative possibilities and seven positive benefits and another option having one negative possibility and four positive benefits. On average people will choose the one negative option. This works as well in politics, the church and in the family as it does in medicine. It is very powerful and can be misused; this brings me back to your point of unethical communication.
People are given or assume authority roles by their position in relation to other people: Doctors, Politicians, and Pastors, as well as Parents, Friends, and Uncles. People in authority should be ethical in their communication but some are not. People in authority should communicate effectively but some do not and can be perceived negatively even as unethical. People in authority are people some ethical some not, some good talkers some not, some having a good day some not. Citizens, parishioners, friends, younger generation and us patients should question our perceptions and not be too quick to form opinions and beliefs. Those beliefs we will be saddled with for a long time. In the end it is our responsibility to communicate, as we would have others communicate with us.
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I look forward to reading the book; I’ll let you know when I get it.
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